<html>

<head>
{php}html_header_show();{/php}

{literal}

 <style type="text/css" title="mystyles" media="all">

<!--

td {

	font-size:12pt;

	font-family:helvetica;

}

li{

	font-size:11pt;

	font-family:helvetica;

	margin-left: 15px;

}

a {

	font-size:11pt;

	font-family:helvetica;

}

.title {

	font-family: sans-serif;

	font-size: 12pt;

	font-weight: bold;

	text-decoration: none;

	color: #000000;

}



.form_text{

	font-family: sans-serif;

	font-size: 9pt;

	text-decoration: none;

	color: #000000;

}



-->

</style>

{/literal}

</head>

<body bgcolor="{$STYLE.BGCOLOR2}">

{literal}

<script language="javascript">



function calculate_bmi(button) {

	bmi = ( ( document.evaluation.wt.value  / ( document.evaluation.ht.value * document.evaluation.ht.value ) ) * 703);

	if (!isNaN(bmi)) {

		document.evaluation.bmi.value = Math.round(bmi*100)/100;

	}

}



</script>

{/literal}

<p><span class="title">Evaluation Examination</span></p>

<form name="evaluation" method="post" action="{$FORM_ACTION}/interface/forms/evaluation/save.php"

 onsubmit="return top.restoreSession()">

<table>

<tr>

	<td>

		<span class=text>TEMP: </span><input size=3 type=entry name="temp" value="{$evaluation->get_temp()}" ></input>

		<span class=text>P: </span><input size=3 type=entry name="p" value="{$evaluation->get_p()}" ></input>

		<span class=text>R: </span><input size=3 type=entry name="r" value="{$evaluation->get_r()}" ></input>

		<span class=text>BP: </span><input size=3 type=entry name="bp" value="{$evaluation->get_bp()}" ></input>

		<span class=text>HT: </span><input size=3 type=entry name="ht" value="{$evaluation->get_ht()}" ></input>

		<span class=text>WT: </span><input size=3 type=entry name="wt" value="{$evaluation->get_wt()}" ></input>

		<span class=text>LMP: </span><input size=10 type=entry name="lmp" value="{$evaluation->get_lmp()}" ></input>

	</td>

<tr>

	<td>

		<span class=text>BMI: </span><input size=5 type=entry name="bmi" value="{$evaluation->get_bmi()}" ></input>

		<input type="button" onClick="calculate_bmi(this);" value="Calculate">

	</td>

</tr>

<tr>

	<td><br><br></td>

</tr>

<tr>

	<td>Chief Complaint</td>

</tr>

<tr>

	<td><p><textarea name="complaint" cols="75" rows="3" wrap="virtual" >{$evaluation->get_complaint()}</textarea></p><br /></td>

</tr>

<tr>

	<td>HPI</td>

</tr>

<tr>

	<td><p><textarea name="hpi" cols="75" rows="3" wrap="virtual" >{$evaluation->get_hpi()}</textarea></p><br /></td>

</tr>

</table>

<table>



{foreach name=loops item=headings key=title from=$checks}

<tr>

	<td>

		{if $smarty.foreach.loops.first ne 1}<br>{/if}

		{$title}

	</td>

</tr>

<tr>

	<td>

	  {foreach item=row key=row_title from=$headings}

			<tr>

				{if !is_numeric($row_title)}

					<td>{$row_title}</td>

					<td class="form_text">{html_checkboxes name="checks" options=$row selected=$evaluation->checks separator="&nbsp;</td><td class=\"form_text\">"}</td>

				{else}

					<td width="20"></td>

					<td colspan="6"><table><tr><td class="form_text">

					

					{html_checkboxes name="checks" options=$row selected=$evaluation->checks separator="&nbsp;&nbsp;&nbsp;</td><td class=\"form_text\">"}

					

					</td></tr></table></td>

					{if $title eq "Eyes" and $row_title == 2}

						</tr>

						<tr>

						<td></td>

						<td class="form_text">OD 20/<input type="text" name="eyes_od" size="4" value="{$evaluation->get_eyes_od()}"></td>

						<td class="form_text">OS 20/<input type="text" name="eyes_os" size="4" value="{$evaluation->get_eyes_os()}"></td>

						<td class="form_text">OU 20/<input type="text" name="eyes_ou" size="4" value="{$evaluation->get_eyes_ou()}"></td>

					{/if}

				{/if}

				

			</tr>

	  {/foreach}

	  

	</td>

</tr>

{/foreach}

</table>

<br><br>

<table>

<tr>

	<td>Comments/Abnormal Findings</td>

</tr>

<tr>

	<td><textarea name="comments" wrap="virtual" cols="75" rows="8">{$evaluation->get_comments()}</textarea></td>

</tr>

<tr>

	<td>Assesment/Plan</td>

</tr>

<tr>

	<td><textarea name="assesment" wrap="virtual" cols="75" rows="8">{$evaluation->get_assesment()}</textarea></td>

</tr>

{if $VIEW != true}

<tr>

	<td><input type="submit" name="Submit" value="Save Form">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;

  <a href="{$DONT_SAVE_LINK}" class="link" onclick="top.restoreSession()">[Don't Save]</a></td>

</tr>

{/if}

</table>

<input type="hidden" name="id" value="{$evaluation->get_id()}" />

<input type="hidden" name="activity" value="{$evaluation->get_activity()}">

<input type="hidden" name="pid" value="{$evaluation->get_pid()}">

<input type="hidden" name="process" value="true">

</form>

</body>

</html>